Madison A. Cameron, PharmDa; Jenna Kawamoto, PharmD, BCACPa; Troy A. Shahoumian, MPH, PhDb; Pamela S. Belperio, PharmD, BCPS, AAHIVPb
Correspondence: Madison Cameron (madison.cameron2@va.gov)
aVeterans Affairs Greater Los Angeles Healthcare System, California
bVeterans Affairs Palo Alto Health Care System, California
Author disclosures
The authors report no actual or potential conflicts of interest or outside sources of funding with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
Ethics and consent
The Veterans Affairs Greater Los Angeles Healthcare System Institutional Review Board determined that this quality improvement study was exempt from review.
From July 2019 to March 2020, 53 veterans were managed by the pharm-PrEP clinic in 98 encounters. Seventy percent of encounters were in-person (Table 1).
We reviewed progress notes, laboratory results, and prescription dispensing to capture prospectively defined data, including specific indications for PrEP, adherence, adverse effects, and reasons for discontinuation. The date of initial visit with the CPP, regardless of whether the patient had been seen by another PrEP prescriber in the past, was considered the baseline visit. Attrition was defined as loss to follow-up for > 1 month after the last expected visit date or no-show to 2 subsequent clinic visits during the evaluation period.
Baseline information collected included demographics, documented patient-reported risk factors, fourth-generation HIV screening test results, STI status, viral hepatitis serologies, and renal function test results. Information collected every 3 to 6 months included STI status, fourth-generation HIV screening test results, renal function test results, adherence to therapy, changes in risk factors, and prescription refill data. Additional interventions conducted as part of clinic workflow included DEXA scans, vaccinations, and active prescriptions for condoms.
Baseline Characteristics
Pharm-PrEP clinic patients were predominantly male (94%), and a majority indicated White race with a median age of 38 years (range, 24-80 years).
About half of the clinic users already were receiving PrEP, 36% were PrEP-naïve, and 15% restarted PrEP after a gap in treatment (Table 2).
Veterans referred to the clinic had up to 5 risk factors for PrEP initiation. The most common risk factors were inconsistent condom use (62%), multiple sexual partners of unknown HIV status (62%), MSM (57%), STI history (38%), bisexual partners (25%), and HIV-positive sexual partners (11%). One of the 53 individuals referred for PrEP had no risk factors and did not initiate PrEP. Two individuals declined initiation of PrEP after consultation. Twenty six of 53 veterans at baseline continued their use of PrEP following transfer to clinic CPP management; 24 of 27 veterans not currently using PrEP (89%) started or restarted lapsed PrEP use following CPP consultation.
HIV and STI Screening
No individuals tested positive for HIV at baseline (n = 52) or while on PrEP. PrEP was not renewed for 3 patients that did follow through with HIV testing. The median number of days an HIV test was completed prior to initial PrEP and PrEP renewal was 4 days and < 7 days, respectively, both of which are below the recommended maximal interval of 7 days, according to CDC PrEP guidelines. Some postinitiation HIV testing occurred using a longer interval of 14 days, in accordance with VA National Criteria for Use of PrEP. This modification allowed more flexibility as a majority of PrEP prescriptions are sent to veterans via mail. The CPP reviewing HIV test results was able to expedite the processing and mailing of PrEP prescriptions if deemed appropriate, ie, the HIV test was negative. This approach was not used if a patient had high-risk exposures without PrEP during the time between collection of the HIV test and mailing of the prescription.
